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The Surviving Sepsis Campaign Bundle: 2018 Update: Special Editorial
The Surviving Sepsis Campaign Bundle: 2018 Update: Special Editorial
https://doi.org/10.1007/s00134-018-5085-0
SPECIAL EDITORIAL
Table 1 Bundle elements with strength of recommendations and under-pinning quality of evidence [12, 13]
Bundle element Grade of recommendation and level of evidence
Measure lactate level. Re-measure if initial lactate is > 2 mmol/L Weak recommendation, low quality of evidence
Obtain blood cultures prior to administration of antibiotics Best practice statement
Administer broad-spectrum antibiotics Strong recommendation, moderate quality of evidence
Rapidly administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L Strong recommendation, low quality of evidence
Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain Strong recommendation, moderate quality of evidence
MAP ≥ 65 mm Hg
It is also important to note that there are no published Obtain blood cultures prior to antibiotics
studies that have evaluated the efficacy in important Sterilization of cultures can occur within minutes of the
subgroups, including burns and immunocompromised first dose of an appropriate antimicrobial [29, 30], so cul-
patients. This knowledge gap needs to be addressed in tures must be obtained before antibiotic administration
future studies specifically targeting these subgroups. The to optimize the identification of pathogens and improve
elements included in the revised bundle are taken from outcomes [31, 32]. Appropriate blood cultures include at
the Surviving Sepsis Campaign Guidelines, and the level least two sets (aerobic and anaerobic). Administration of
of evidence in support of each element can be seen in appropriate antibiotic therapy should not be delayed in
Table 1 [12, 13]. We believe the new bundle is an accurate order to obtain blood cultures.
reflection of actual clinical care.
Administer broad‑spectrum antibiotics
Measure lactate level Empiric broad-spectrum therapy with one or more intra-
While serum lactate is not a direct measure of tissue venous antimicrobials to cover all likely pathogens should
perfusion [22], it can serve as a surrogate, as increases be started immediately [21] for patients presenting with
may represent tissue hypoxia, accelerated aerobic gly- sepsis or septic shock. Empiric antimicrobial therapy
colysis driven by excess beta-adrenergic stimulation, or should be narrowed once pathogen identification and
other causes associated with worse outcomes [23]. Ran- sensitivities are established, or discontinued if a decision
domized controlled trials have demonstrated a significant is made that the patient does not have infection. The link
reduction in mortality with lactate-guided resuscitation between early administration of antibiotics for suspected
[24–28]. infection and antibiotic stewardship remains an essential
If initial lactate is elevated (> 2 mmol/L), it should be aspect of high-quality sepsis management. If infection
remeasured within 2–4 h to guide resuscitation to nor- is subsequently proven not to exist, then antimicrobials
malize lactate in patients with elevated lactate levels as a should be discontinued.
marker of tissue hypoperfusion [24].
Administer intravenous fluid Acknowledgements
The authors gratefully acknowledge Deb McBride and Lori Harmon for their
Early effective fluid resuscitation is crucial for the stabi- invaluable assistance with manuscript preparation and editing (DM) and
lization of sepsis-induced tissue hypoperfusion or septic overall support for this work (DM and LH).
shock. Given the urgent nature of this medical emer-
Compliance with ethical standards
gency, initial fluid resuscitation should begin imme-
diately upon recognizing a patient with sepsis and/or Conflicts of interest
hypotension and elevated lactate, and completed within Dr. Levy is a Member of the Surviving Sepsis Campaign Executive Committee
and is a Surviving Sepsis Campaign Guidelines Author. Dr. Evans is a Member
3 h of recognition. The guidelines recommend this of the Surviving Sepsis Campaign Steering Committee and is a Surviving
should comprise a minimum of 30 ml/kg of intravenous Sepsis Campaign Guidelines Co-Chair. Dr. Rhodes is a Member of the Surviving
crystalloid fluid. Although little literature includes con- Sepsis Campaign Executive Committee and is a Surviving Sepsis Campaign
Guidelines Co-Chair.
trolled data to support this volume, recent interventional
studies have described this as usual practice in the early
stages of resuscitation, and observational evidence is sup- Received: 5 January 2018 Accepted: 1 February 2018
portive [7, 8]. The absence of any clear benefit following
the administration of colloid compared with crystalloid
solutions in the combined subgroups of sepsis, in con-
junction with the expense of albumin, supports a strong References
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